Performance Training & Programming Intake Logo
  • Performance Training & Programming Intake

    Personal Information
  •  -
  •  -

  • In case of an emergency:

  •  -


  • 1/5

  • Performance Training/Programming Intake

    Patient Acknowledgements
  • Please read the information below before signing. 

  • Card on File Authorization

     

    I authorize Healing Motion Physical Therapy, Inc. to securely store my credit card information on file for the purpose of processing any outstanding balances prior to each performance training appointment or before the completion of any programming for the current month. Additionally, if I am enrolled in a monthly programming subscription through Train Heroic and carried out by a Healing Motion coach, I consent to Healing Motion Physical Therapy, Inc. charging my card on the 1st of each month until either party provides notice of cancellation.

  • Clear
  • CANCELLATION POLICY


    Performance Training Appointments
    Attendance at all scheduled appointments is extremely important. Our appointments are on a 45-minute basis. If you are late for your appointment, your coach may feel it necessary to do only a portion of your session or reschedule for another day. If a scheduling conflict occurs, please call us as soon as possible. We may be able to use your time for another client and reschedule you for a more convenient time.

    Performance Training Appointment Fee Policies
    I understand that the responsibility for attending appointments that are scheduled is mine. If desired, a reminder card will be given when the appointment is scheduled. Additionally, an appointment reminder will be sent to you prior to each appointment. If a no show, late cancellation, or late arrival occurs, you will be billed at the following rate:

    • NO SHOW: If you do not arrive to a scheduled appointment you will be billed the full performance training session amount of $150.
    • LATE CANCELLATION: We ask for at least 24-hours’ notice for cancellations. If you call to cancel with less than 24-hours’ notice, you will be billed $90.
    • LATE ARRIVAL: If you arrive late to your scheduled appointment, you will still be required to pay the full performance training session amount of $150.

    Monthly Subscription Cancellations
    For clients enrolled in monthly programming subscriptions, a 30-day notice is required for cancellation. If you wish to cancel your subscription, please notify us at least 30 days before the next billing cycle, which begins on the 1st of each month. Refunds will not be issued for late notice of a monthly subscription cancellation.

  • Clear

  • 2/5

  • Performance Training/Programming Intake

    Social History

  • 3/5

  • Performance Training/Programming Intake

    History of Current Condition
  • I am currently training days per week for a total of hours per week.




  • 4/5

  • Performance Training/Programming Intake

    Medical History
  • Please select all medical conditions you currently have or have had in the past. 








  • Upload OR type out your current medication and supplement list below.

  • UPLOAD
    Cancelof

  • 5/5

  • Should be Empty: